| Who Pays First If A Beneficiary Has Part D and…. | Answer |
| Is also covered under a State Pharmaceutical Assistance Program (SPAP)? | SPAP coverage is secondary to Part D, so the beneficiary’s Part D plan will pay first. |
| Is retired and is covered through the former employer’s retiree Group Health Plan (GHP)? | When a beneficiary is covered through a retiree GHP, the GHP is secondary to Part D. The beneficiary’s Part D plan will pay first. |
| Is also covered under the GHP of a retired spouse? | When the beneficiary is covered through the GHP of a retired spouse, the GHP is secondary to Part D. The Part D plan will pay first. |
| Has retiree GHP coverage and is covered under their spouse’s retiree GHP? | Because the beneficiary and spouse are both retired, the two GHPs are secondary to Part D. The Part D plan will pay first, and then the beneficiary’s own GHP will be billed second, followed by the spouse’s GHP if there is any remaining balance. |
| Has both retiree GHP coverage and SPAP coverage? | Part D is primary to both the retiree GHP coverage and the SPAP coverage. The Part D plan will pay first, and then the GHP coverage would be billed second, followed by the SPAP if there is any remaining balance. |
| Is also covered under Medicaid? | Medicaid only pays for drugs for Part D beneficiaries when those drugs are not allowed to be covered by Part D. Therefore, people who are covered under both Part D and Medicaid will never have drugs that are paid for by both types of coverage. Either the Part D plan will pay, or Medicaid will. |
| Is covered under both a retiree GHP and Medicaid? | The retiree GHP is secondary to Part D. Medicaid is a “payer of last resort,” so it is secondary to the GHP. If the drug is covered under Part D, the Part D plan will pay first and then the GHP will be billed, but Medicaid will not because it cannot pay for Part D-covered drugs. If the drug is not a Part D-covered drug, the GHP will be billed first and then Medicaid. |
| Is currently working with coverage through the employer’s Group Health Plan (GHP)? | When a beneficiary is covered through their employer’s GHP because they are actively working, generally Part D is secondary to the GHP. The GHP will generally pay first. (depends on the number of actively working individuals) |
| Is also covered under the employer GHP of an actively working spouse? | When a beneficiary is covered through the GHP of an actively working spouse, generally Part D is secondary to the GHP. The GHP generally will pay first. (depends on the number of actively working individuals) |
| Is also covered under worker’s compensation (WC)? | Worker’s compensation is primary to Part D for all drugs that are related to the WC injury or illness. The WC plan will be billed for all such drugs first, and the Part D plan will be billed second. If the drug is not related to the WC injury or illness, then only the Part D plan will be billed. |
| Also has no-fault or liability coverage? | If the beneficiary was injured or fell ill and has no-fault or liability coverage (such as when you are in a car accident), the no-fault or liability coverage is primary to Part D for all drugs that are related to that injury or illness. Therefore, the no-fault/liability coverage will be billed for all such drugs first, and the Part D plan will be billed second. |
| Source: Centers for Medicare and Medicaid (CMS) WhatIfCOB_01.04.06.pdf | |
Medicare Part D Coordination of Benefits with Other Programs. Who Pays First?
Your Medicare plan coverage · published May 29, 2008